Trauma pathophysiology

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Trauma pathophysiology

  1. 1. PATHO-PHYSIOLOGY (& MX) OF TRAUMA Dr Aoibhin Hutchinson 27th September 2013 Monday, 21 October 13
  2. 2. THE REAL TRAUMA INTERFACE Monday, 21 October 13
  3. 3. TRAUMA LOGISTICS Monday, 21 October 13
  4. 4. MAJOR TRAUMA CENTRE • 24 hours a day, fully staffed ED • Consultant led trauma team • Dedicated trauma theatres & operating lists • All major specialties: • Ortho, general, vascular, neuro, plastics, cardiothoracic, head & neck, urology • Interventional • Anaesthesia Monday, 21 October 13 radiology & Critical care
  5. 5. • High volume trauma centres reduce mortality from major injury by 50%. 1 • (high volume > 20 cases per week) • Time from trauma to definitive surgery / intervention is the primary determinant of outcome in major trauma (not time to ED). 2 1. Relationship Between Trauma Center Volume and Outcomes. Nathens A et al, JAMA. 2001;285:1164-1171 2. Resources for Optimal Care of the Injured Patient. American College of Surgeons, 1999 • Monday, 21 October 13
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  7. 7. Jim McGuigan Thoracic Surgeon Royal Victoria Hospital Belfast Monday, 21 October 13
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  10. 10. ATLS Monday, 21 October 13
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  12. 12. No  major  changes   to  thoracic Though  role  of  US   Monday, 21 October 13 No  springing  pelvis Binder  on  early Pan  scan Use  of  focused   ECHO  /  US
  13. 13. SURVIVING TRAUMA •Early patho-physiology: •Immediate threat to life •ABC •Longer term patho-physiology: •Surviving critical care (prolonged care phase) •MOF / Sepsis Monday, 21 October 13 ATLS: Trimodal death distribution
  14. 14. AIMS 1.What’s important in the early resuscitative phase? 2.What important in the critical care in recovery phase? Monday, 21 October 13
  15. 15. BASIC TRAUMA PATHO-PHYSIOLOGY in a word - bleeding Monday, 21 October 13
  16. 16. •Define shock ....an abnormality of the circulatory system that results in inadequate organ perfusion and delivery of oxygen •Classify shock •Haemorrhagic / hypovolaemic •Cardiogenic •Obstructive •Distributive •Septic •Neurogenic Monday, 21 October 13
  17. 17. CO = HR x SV BP = CO x SVR Monday, 21 October 13
  18. 18. BLEEDING... Clinically: Blood%loss% •Tachycardic Decreased%IV%volume% •Hypotensive Reduced%venous%return% (preload)% •Narrow pulse pressure •Cold peripheries / shut down Decreased%stroke%volume% Lowered%CO% Reduced%BP%% Hypoperfusion%of%Assues% Compensatory • Increase SVR • Increase HR To preserve CO / BP Monday, 21 October 13 Tissue%hypoxia% MODs%
  19. 19. MANAGEMENT AIMS Control the bleeding Correct coagulopathy Restore IV volume Preserve organ perfusion Monday, 21 October 13
  20. 20. WHAT’S NEW? Monday, 21 October 13
  21. 21. Triad of Death 1.Coagulopathy 2.Acidosis 3.Hypothermia Vicious circle rather than a triangle SIRS CARS Acute Traumatic Coagulopathy 25% trauma pts have established coagulopathy (ATC) on presentation - 4 fold increase in mortality Brohi K, Singh J, Heron M, Coats T. Acute traumatic coagulopathy. J Trauma 2003;54:1127-30. MacLeod JB, Lynn M, McKenney MG, Cohn SM, Murtha M. Early coagulopathy predicts mortality in trauma. J Trauma 2003;55:39-44. Maegele M, Lefering R, Yucel N, Tjardes T, Rixen D, Paffrath T, et al. Early coagulopathy in multiple injury: an analysis from the German Trauma Registry on 8724 patients. Injury 2007;38:298-304. Monday, 21 October 13
  22. 22. WHAT’S ‘RELATIVELY’ NEW? •Fluid resuscitation •Permissive hypotension •Haemostatic resuscitation •Blood product administration ratios •Military approach: Damage control resuscitation •Tranexamic acid •Damage control Sx •Interventional radiology Monday, 21 October 13
  23. 23. AKI Monday, 21 October 13 Mortality
  24. 24. FLUIDS  Increasing evidence for crystalloid  Hyperoncotic Colloid:  Increased risk AKI 6S STUDY  Increased mortality CHEST STUDY Monday, 21 October 13
  25. 25. • June 20th 2013: Joint position statement from FICM, RCOA, ICS, College of EM following on from European Medicines Agency suspending marketing authorisation for HES due to risks outweighing any perceived benefits • Applies equally to pts with hypovolaemia, hypovolaemic shock, critically ill patients including those with sepsis, burns, trauma and those undergoing surgery Monday, 21 October 13
  26. 26. EMA DECISION BASIS •1. Perner A, Haase N, Guttormsen AB, et al. Hydroxyethyl starch 130/0.42 versus Ringer's acetate in severe sepsis. N Engl J Med 2012;367:124-34. (6S Study) •2. Brunkhorst FM, Engel C, Bloos F, et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med 2008;358:125-39. (VISEP study) •3. Myburgh JA, Finfer S, Bellomo R, et al. Hydroxyethyl starch or saline for fluid resuscitation in intensive care. N Engl J Med 2012;367:1901-11. (CHEST Study) Monday, 21 October 13
  27. 27. Monday, 21 October 13
  28. 28. PERMISSIVE HYPOTENSION • Fluid resuscitating • a patient who is no longer bleeding is easy • a patient with ongoing bleeding is much more complicated: huge potential to make the patient worse your endpoints are much more important • Increasingly accepted view that moderate hypotension (Systolic <90mmHg) in trauma patients without TBI is sufficient to maintain critical organ perfusion (but pressure = flow) • Resuscitating to >90mmHg runs the risk of clot dislodgment & vicious circle formation Monday, 21 October 13
  29. 29. NOT SO NEW? Monday, 21 October 13
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  32. 32. NICE 2004 : PRE HOSPITAL Monday, 21 October 13
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  34. 34. RESUSCITATION OF THE BLEEDING PATIENT • Rather than aggressive fluid replacement, the ability to control ongoing blood loss is one of the most important determinants in the outcome of a seriously injured patient. Hess JR, Holcomb JB, Hoyt DB: Damage control resuscitation: The need for specific blood products to treat the coagulopathy of trauma. Transfusion 2006;46:685-6.  Don’t obsess about fluid resuscitation ....control the source of bleeding Monday, 21 October 13
  35. 35. RESUSCITATION • Coapulopathy (ATC) occurs much earlier than we thought & is a major driver • Haemorrhage control is the priority • Do not delay transfer to place of definitive control transfer but use with caution • Permissive hypotension - arguable for - really relevant to prehospital • Clinical end points of resuscitation are uncertain - we are stuck with BP (Sys 100; Hb 7-8; plts100; INR<1.5; fibrinogen>1) Monday, 21 October 13
  36. 36. BLOOD -HAEMOSTATIC RESUS -MASSIVE TRANSFUSION -BLOOD PRODUCT RATIOS Monday, 21 October 13
  37. 37. MASSIVE TRANSFUSION • emerging opinion that massive transfusion of red cells and clotting factors in trauma patients should be given in broadly similar proportions from the outset Borgman MA, Spinella PC, Perkins JG, Grathwohl KW, Repine T, Beekley AC, et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma 2007;63:805-13. Monday, 21 October 13
  38. 38. PRBC : FFP : PLTS: CRYO Borgman MA, Spinella PC, Perkins JG, Grathwohl KW, Repine T, Beekley AC, et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma 2007;63:805-13. Monday, 21 October 13
  39. 39. Monday, 21 October 13
  40. 40. DILUTIONAL COAGULOPATHY Monday, 21 October 13
  41. 41. ACUTE TRAUMATIC COAGULOPATHY (ATC) & TRAUMA INDUCED COAGULOPATHY (TIC) Monday, 21 October 13
  42. 42. DIAGNOSING ATC •It is a nightmare.....blind •PT & APTT - only describe isolated fragments of the haemostatic process •Always delays •Next set sent before first set back •If it were easy & quick - decisions about blood product ratios would not have to be preemptive Typical example of time to receiving PT result Monday, 21 October 13
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  48. 48. TRANEXAMIC ACID Monday, 21 October 13
  49. 49. TRANEXAMIC ACID • Direct trauma causes activation of fibrinolysis • CRASH 2 June 2010, The Lancet • Over 20,000 pts; 274 hospitals, 40 countries • Admin <8hrs from injury:1gm over 10mins & then 1gm over 8hours • Administration of Tranexamic acid reduced the risk of death in bleeding trauma victims (14.5% vs 16%) • No increase in vascular occlusive events Monday, 21 October 13
  50. 50. June 2010 March 2011 Monday, 21 October 13
  51. 51. TRANEXAMIC TIMING • Early Rx <1hr from injury: • Mortality • Rx 1-3hrs from injury: • Mortality • Rx due to bleeding 5.3% (vs 7.7% placebo) due to bleeding 4.8% (vs 6.1% placebo) > 3hrs from injury: • Seemed to increase risk of death due to bleeding 4.4% (vs 3.1% placebo)......Unclear why Monday, 21 October 13
  52. 52. CRASH 2 - TIMING Monday, 21 October 13
  53. 53. TRANEXAMIC ACID • In bleeding trauma victims: Give it! • CRASH 2: 32% reduction in death if given <1hr • Give it ASAP (<3hrs) :1gm over 10mins (followed by 1gm over 8hrs) • Given early it effects ATC: prevents full activation of fibrinolysis which once started is difficult to abate • Pre hospital care may be where its role is best placed • Caution in those who present several hours after injury Monday, 21 October 13
  54. 54. LESSONS FROM CONTMEPORARY WAR • Transfusion policies •Rx blast injury • Liberal use of tourniquets •Use of haemostatic •Joint theatre system •Critical care air transport team •Use of US & IO needles Monday, 21 October 13 dressings •PTSD
  55. 55. MILITARY APPROACH • Definitive care quickly • Permissive • Early hypotension administration of blood: • Haemostatic • High resus ratio PRBC : FFP : Plts • Tranexamic • Damage acid control resuscitation & surgery (DCR / DCS) Monday, 21 October 13
  56. 56. DIFFERENCES • Military • Pre Mx & non military hospital & In hospital • Penetrating injuries • Patients- Monday, 21 October 13 / blunt / blast demographics
  57. 57. INCOMPLETELY ANSWERED QUESTIONS • Which patients would benefit most from haemostatic resus? • How do we identify them at the outset? • What is the optimal ratio PRBCs : FFP : Plts ? • Which pts will benefit most from permissive hypotension? • Precise indications for recombinant factor VII, tranexamic, cryo, calcium? • Does the storage age of the blood matter? Monday, 21 October 13
  58. 58. CONCLUSION • Trauma is a leading cause of death in young people: haemorrhagic shock is the leading cause of mortality • Control of bleeding is paramount: therefore rapid transfer is a priority • Permissive hypotension has a role in pre hospital care • Coagulopathy develops early & is an independent risk factor for death - aggressive Mx • Tranexamic acid should be given early - ideally pre hospital • Lessons to be learnt from Military approach - but be objective: different patients, injuries & situation • Haemostatic resus: high ratio of products needed; likely 1:2; who stands to benefit most? • Further Evidence base is required Monday, 21 October 13
  59. 59. AIMS 1.What’s important in the early resuscitative phase? 2.What important in the critical care in recovery phase? Monday, 21 October 13
  60. 60. • Trauma World is a major cause of mortality in <50yrs in Western • Mortality due to sustained injuries (early) • Subsequent • About Monday, 21 October 13 immune reactions (late) & resultant MOF 5% trauma patients develop post traumatic MOF
  61. 61. TRAUMA & MOF Endogenous factors susceptibility to MOF •genetics •physical condition Exogenous factors •Injuries themselves (1st hit: trauma load) •Resuscitation strategy & Surgery (2nd hit: intervention load) Organ damage & then failure is due to dysfunctional immune response Monday, 21 October 13
  62. 62. Monday, 21 October 13
  63. 63. SIRS • Fever >38 or <36 • HR >90 • RR >20 or PCO2 < 4.3kPa • WC >12 or <4 or > 10% immature bands Monday, 21 October 13 Precipitants: • Tissue injury • Hypoxia • Hypovolamia • Hypercarbia • Infection
  64. 64. Monday, 21 October 13
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  68. 68. PROPHYLAXIS • Address nutritional needs • Preventing ulceration stress bleeding, venous thrombosis & pressure • Assessing antimicrobial prophylaxis, tetanus status & preventing • Consider LPV HCAIs • FAST Monday, 21 October 13 HUG
  69. 69. OTHER TOPICS TO MENTION • Hypothermia • EPO in trauma? • Statins Monday, 21 October 13 in trauma? in trauma?

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